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A 25-year-old male is brought to the emergency room with a piece of metal in his eye. The first action the nurse should take is:
- A. Use a magnet to remove the object.
- B. Rinse the eye thoroughly with saline.
- C. Cover both eyes with paper cups.
- D. Patch the affected eye.
Correct Answer: C
Rationale: Covering both eyes prevents eye movement, reducing further damage.
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The toddler is admitted with a cardiac anomaly. The nurse is aware that the infant with a ventricular septal defect will:
- A. Tire easily
- B. Grow normally
- C. Need more calories
- D. Be more susceptible to viral infections
Correct Answer: A
Rationale: A ventricular septal defect causes increased pulmonary blood flow, leading to easy tiring due to cardiac workload.
The home health nurse is planning for the day's visits. Which client should be seen first?
- A. The 78-year-old who had a gastrectomy 3 weeks ago and has a PEG tube
- B. The 5-month-old discharged 1 week ago with pneumonia who is being treated with amoxicillin liquid suspension
- C. The 50-year-old with MRSA being treated with Vancomycin via a PICC line
- D. The 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter
Correct Answer: B
Rationale: The 5-month-old with recent pneumonia is at high risk for complications, prioritizing their assessment.
A client is prescribed heparin 2,000 units SC q8 hours. The pharmacy sends heparin 5,000 units/mL. How many mL should the nurse administer every 24 hours?
- A. 0.4 mL/day
- B. 0.8 mL/day
- C. 1.2 mL/day
- D. 1.4 mL/day
Correct Answer: C
Rationale: Dose per injection: 2,000 units ÷ 5,000 units/mL = 0.4 mL. Q8 hours = 3 doses/day. 0.4 mL × 3 = 1.2 mL/day.
A client has orders for a heparin drip with 20,000 units in a 250 mL bag. The heparin must be delivered at 854 units per hour. What rate will the nurse set for the IV?
Correct Answer: 10.7 mL/hr.
Rationale: Concentration: 20,000 units/250 mL = 80 units/mL. Rate: 854 units/hr ÷ 80 units/mL = 10.675 mL/hr, rounded to 10.7 mL/hr.
The primary reason for rapid continuous rewarming of the area affected by frostbite is to:
- A. Lessen the amount of cellular damage
- B. Prevent the formation of blisters
- C. Promote movement
- D. Prevent pain and discomfort
Correct Answer: A
Rationale: Rapid rewarming minimizes cellular damage by restoring blood flow and preventing further tissue injury in frostbite.